This paper takes as its starting point the paper by Aubrey Lewis entitled “The psychopathology of insight” published in 1934, unreferenced.

To attempt to explore the historical antecedents and consequences of this work.

Speculative review.

Lewis's approach to phenomenology, contemporaneous movements in psychology and Lewis's own life and times – notably the eugenics legislation in Nazi Germany – probably shaped his conclusions. Modern concepts of insight, which emphasise neuropsychology as well as social psychology, were anticipated in Lewis's writings.

The concept of insight has stimulated research into difficult theoretical and practical areas such as self-awareness and treatment compliance, respectively. Concern over a patients capacity for insight has the potential to humanise psychiatry.

Randomised controlled trials (RCTs) are the most important method of evaluating new treatments and treatment policies. Despite this, there are relatively few large pragmatic RCTs in psychiatry.

To explore the main advantages of large pragmatic RCTs and the obstacles to performing them in psychiatry.

A narrative review of literature on pragmatic RCTs with examples drawn from psychiatry and other medical specialities.

Obstacles to performing pragmatic RCTs in psychiatry include the complexity of psychiatric interventions, the complexity of outcomes used in psychiatry and the difficulties of blinding subjects and investigators to some psychiatric interventions.

Researchers need to frame questions in a form that is relevant to clinicians and to convince clinicians to cooperate in simple large pragmatic trials.

A considerable proportion of patients with personality disorder are discharged directly to the community from special (high-security) hospitals.

To examine whether patients with personality disorder discharged directly to the community are more likely to be re-convicted than those transferred to psychiatric hospitals of lesser security.

Re-conviction data for a f ive-to nine-year follow-up were collected for a four-year (1988–1991) special hospital discharge cohort of patients with personality disorder.

Individuals discharged directly to the community were not significantly more likely to be re-convicted than those transferred to less secure psychiatric hospitals. However, patients discharged to the community without formal conditions of supervision were more likely to be re-convicted than those discharged to the community with conditions or those transferred to other psychiatric hospitals.

Formal supervision after discharge may be more important than actual destination in influencing the likelihood of re-conviction.

Electroconvulsive therapy (ECT) is a controversial treatment for psychiatric disorders, particularly when it is administered to young people.

To assess how frequently ECT is administered to people under the age of 18 years in the UK, and why it is given.

Electroconvulsive therapy clinics, private hospitals, adolescent units and UK members of the Royal College of Psychiatrists were surveyed to ask if they were aware of ECT being administered during 1996 to a young person under the age of 18 years. Consultants identified as having prescribed ECT were sent a follow-up questionnaire.

Twelve young people were identified as having received ECT; three were aged 15 years or younger and eight were female. Nine patients were rated as improved following ECT. The indications for its use were similar to those for adults.

Electroconvulsive therapy is rarely administered to young people in the UK.

The dopamine hypothesis proposes that antipsychotic drugs act primarily through limbic cortical D2/D2-like dopamine receptor blockade.

To evaluate this hypothesis with the D2/D3-selective SPET probe [123I]-epidepride.

[123I]-epidepride SPETscans were performed on 12 patients with schizophrenia treated with antipsychotics and 11 age-matched healthy controls. [123I]-epidepride specific binding to D2/D3 dopamine receptors was estimated, and relative percentage D2/D3 receptor occupancy by typical antipsychotic drugs determined.

Mean (s.d.) daily dose was 669.12 (516.8) mg chlorpromazine equivalents. Mean percentage D2/D3 receptor occupancy was 81.6 (8.1) and 73.2 (13.9) in the temporal cortex and striatum respectively.

Typical antipsychotic drug treatment is associated with substantial temporal cortical D2/D3 receptor occupancy. The relationship between this and efficacy is poor in patients with treatment-resistant schizophrenia.

There is conflicting evidence about the frequency of adverse pregnancy outcomes among women with schizophrenia.

To investigate the risk of preterm birth, low birth weight and intra-uterine growth retardation among women with schizophrenia.

A total of 2212 births to 1537 women with schizophrenia in Denmark were compared with a random sample of all deliveries in Denmark in 1973–1993 (122 931 births to 72 742 women)

The children of women with schizophrenia were at increased risk of preterm delivery (relative risk=1.46, 95% CI=1.19–1.79), low birth weight (relative risk=1.57, 95% 0=1.36–1.82) and small for gestational age (relative risk=1.34, 95% CI=1.17–1.53)

Women with schizophrenia are at increased risk of adverse pregnancy outcome. This may be associated with an increased mortality and general morbidity and risk of schizophrenia in their children.

The assumption that patients with bipolar disorder make a full inter-episode recovery has been challenged by limited evidence that suggests that neuropsychological dysfunction in bipolar disorder may persist beyond episodes of illness.

To test the hypothesis that patients with euthymic bipolar disorder show neuropsychological impairment.

A battery of neuropsychological tests (assessed attention, working memory, learning and executive function) was administered to three matched groups of subjects: good-outcome patients with bipolar disorder (n=21); poor-outcome patients with bipolar disorder (n=20); controls (n=20). All patients were clinically euthymic, although some had low levels of depressive symptoms.

Patients performed worse than controls on a number of neuropsychological tests. When age, premorbid IQ and depressive symptoms were controlled for, the results indicated impairment of executive function.

These findings provide good evidence for the existence of neuropsychological impairment in patients with euthymic bipolar disorder, although the possible effect of medication should not be overlooked. This may be of clinical relevance and raises questions about the course and outcome of the illness.

Imaging studies in depression of the elderly are often small and highly selective.

To investigate a large group of elderly depressed patients in order to assess changes in clinical, imaging and neuropsychological variables at follow-up.

Patients (n=175, age range 65–91 years) with clinical depression were identified from consecutive local referrals. Clinical interviews, neuropsychological tests and SPECT scans were carried out at referral and at two-year follow-up.

Of 84 re-examined patients, 46.5% were well, 9.5% were ill, 33% partially recovered and 11% had developed dementia. Duration of illness before index assessment was the only factor to predict outcome. Thirty-nine patients could be scanned and followed up. There were no differences between patients with good or poor depressive outcome on SPECT. Ten clinically improved patients could be re-examined with SPECT. There were relative increases in right cingulate gyrus and right cerebellum at follow-up.

The patient group was comparable with other studies showing high levels of residual depressive symptoms. Activity changes in limbic cortex are implicated in depression of old age.

It has been suggested that low serum total cholesterol is associated with an increased risk of suicide.

To study the association between serum total cholesterol, depression and suicide using versatile, prospective data.

A total of 29 133 men aged 50–69 years were followed up for 5–8 years. Baseline blood samples were analysed for serum total and high-density lipoprotein cholesterol concentrations. Self-reported depression was recorded, data on hospital treatments due to depressive disorders were derived from the National Hospital Discharge Register and deaths from suicide were identified from death certificates.

Low serum total cholesterol was associated with low mood and subsequently a heightened risk of hospital treatment due to major depressive disorder and of death from suicide.

Our results suggest that low serum total cholesterol appears to be associated with low mood and thus to predict its serious consequences.

The influence of the macro-economic climate on suicide is unclear. During the recent recession, rates have increased in young males but declined in females.

To investigate associations between unemployment and suicide in 15 – to 44-year-old men and women over a period spanning two major economic recessions (1921–1995). To minimise confounding by changes in method availability, analyses are restricted to suicides using methods other than poisons and gases.

Time-series analysis using routine mortality and unemployment data.

There were significant associations between unemployment and suicide in both males and females. Associations were generally stronger at younger ages.

Secular trends in youth suicide may be influenced by unemployment or other factors associated with changes in the macroeconomic climate. These factors appear to affect women to the same extent as men. Although it is not possible to draw firm aetiological conclusions from time-trend data, our findings are in keeping with those of person-based studies.

Suicide rates in youngmales in the UK have risen markedly in recent years.

To investigate the characteristics of a series of consecutive suicides in under-25-year-olds.

We studied coroners' inquest notes, general practitioners' records and psychiatric case notes of 174 individuals (148 males and 26 females) whose deaths received a verdict of suicide or an open or accidental verdict (excluding traffic accidents) where the circumstances strongly suggested suicide.

More individuals were of lower social class and unemployed than in the local population. Hanging and carbon monoxide poisoning were the most frequent methods of suicide, and co-proxamol was the drug most often used in overdoses. Previous self-harm had occurred in 44.8%, nearly half of these having carried out multiple episodes and 80% having self-harmed within the previous year. Little support was found for an earlier finding of increasing frequency of general practitioner visits shortly before death. Only 22.4% of individuals were in the care of psychiatric services.

Diverse strategies are required to prevent suicide in the very young.

The extent of suicide among addicts in the UK has not been sufficiently examined.

To examine suicide trends among registered addicts in the UK over a 25-year period.

We quantified suicide using International Classification of Diseases (ICD) external death codes E950–959, calculated annual age-standardised suicide rates, standardised mortality ratios (SMRs) and described trends in methods of suicide and drug overdose suicides in five successive cohorts of registered addicts.

Male and female suicide rates are 69.0 and 44.8 per 100 000 person-years, respectively. There was a consistent decline in suicide rate throughout the 25-year period. Among males, the SMR for suicide declined from 17.2 in 1968–1972 to 4.4 in 1988–1992 (SMR ratio=3.9, 95% CI=2.5–6.1); among females it declined from 52.6 to 11.3 in the same period (SMR ratio=4.7, 95% CI=1.9–10.8). Drug overdose was the most common method of suicide, accounting for 45% of cases. Significant increase in antidepressant (percentage difference=23.5%, 95% CI=15.2–31.8) and methadone (percentage difference=1.0%, 95% CI=0.5, 21.5) overdose in 1988–1992 compared with 1968–1972 was reported.

The findings confirm that addicts are still at higher risk of suicide than the general population and that prescribed drugs, notably antidepressants and methadone, influence this heightened risk.

Authors have suggested that the high rate of schizophrenia reported for African–Caribbeans living in the UK is due to misdiagnosis by British psychiatrists.

To compare the diagnoses made by a Black Jamaican psychiatrist with those of White British psychiatrists.

All in-patients on four wards at the Maudsley hospital were approached for the study; 66 participated: 24 White, 29 Black African–Caribbeans and 13 Blacks from other countries of origin. F. W. H., a Black Jamaican psychiatrist, conducted his standard clinical assessment and performed the Present State Examination (PSE) on these patients. His diagnoses were compared with the case note diagnoses made by British psychiatrists, and with the PSE CATEGO diagnoses.

Of 29 African and African–Caribbean patients diagnosed with schizophrenia, the diagnoses of the British and the Jamaican psychiatrists agreed in 16 instances (55%) and disagreed in 13 (45%). Hence, interrater reliability was poor (κ=0.45). PSE CATEGO diagnosed a higher proportion of subjects as having schizophrenia than the Jamaican psychiatrist did (χ2=3.74, P=0.052)

Agreement between the Jamaican psychiatrist and his UK counterparts about which patients had schizophrenia was poor. PSE CATEGO may overestimate rates of schizophrenia.